Chest Pain with Health Anxiety

Clinical Scenario

Aiden Clarke, 24, a postgraduate student, presents with recurrent sharp left-sided chest pains over the past 3 weeks. The pain is stabbing, lasts seconds to minutes, is worse when he takes a deep breath or moves his upper body, and is reproducible on palpation of the chest wall. He has no exertional component, no radiation, and no associated breathlessness, palpitations, or syncope. His father had a myocardial infarction aged 52. He has been checking his pulse 20-30 times daily, has attended A&E twice in the past month with normal ECGs and troponin, and has been reading extensively about cardiac conditions online. He wants a cardiac referral.

What This Case Tests

Conducting a thorough assessment that confidently excludes cardiac pathology; identifying musculoskeletal chest pain from the history and reproducibility on palpation; recognising the pattern of health anxiety — repeated presentations, safety behaviours, catastrophic interpretation of benign symptoms; addressing the father's MI as the specific anxiety trigger; explaining why further cardiac investigation is not indicated and may be harmful; offering a management pathway for the health anxiety itself

Common Mistakes Trainees Make

The three most common mistakes are: referring to cardiology to reassure the patient, when two normal A&E assessments already provide robust cardiac exclusion and further investigation reinforces the health anxiety cycle; dismissing his chest pain as 'nothing' without providing a positive diagnosis (musculoskeletal chest pain) and a credible explanation of what is causing it; and failing to identify or address the health anxiety as a condition in its own right that needs treatment, instead focusing solely on excluding cardiac disease.

The Consultation Challenge

Aiden is caught in a health anxiety cycle: chest pain triggers fear of a heart attack, fear triggers hypervigilance and checking, checking maintains the anxiety, and anxiety causes muscle tension that worsens the chest pain. His father's MI at 52 is the specific trigger that has made him catastrophise a benign symptom.

Start with a thorough assessment. Even though he has had two normal A&E attendances, he needs to feel properly assessed by you. Ask about the pain characteristics systematically: location, character, duration, radiation, aggravating and relieving factors. The key diagnostic features are: sharp and stabbing (not crushing), lasting seconds to minutes (not sustained), worse with breathing and movement (positional), reproducible on palpation (musculoskeletal), and no exertional component. These features are inconsistent with cardiac pain and classic for musculoskeletal chest wall pain.

Provide a positive diagnosis: 'Aiden, I have gone through your symptoms very carefully, and I want to tell you what I think this IS, not just what it is not. The pain you are describing is musculoskeletal — it is coming from the muscles and joints in your chest wall. I know that because it is sharp, it changes with movement and breathing, and I can reproduce it by pressing on the area. Cardiac pain does not behave like this — it does not come and go in seconds, it is not sharp, and you cannot reproduce it by pressing.'

Address his father's MI directly: 'I can see that your dad's heart attack is at the front of your mind, and that is completely understandable. But your risk profile is completely different — you are 24, you have had two normal ECGs and normal blood tests, and the type of pain you have is not cardiac. Your dad's history means I would recommend a cardiovascular risk assessment when you are older, but it does not make you at risk of a heart attack at 24.'

Name the health anxiety: 'I want to talk about something else I have noticed. You have been to A&E twice, you are checking your pulse 20-30 times a day, and you have been reading about heart conditions online. These are signs that anxiety about your health has become a problem in its own right. The anxiety is real, the chest pain is real, but they are connected — the worry is causing muscle tension that makes the chest wall pain worse, and the pain reinforces the worry.'

Explain why further investigation is counterproductive: 'I know you want a cardiac referral, and I understand why. But here is the problem — if I refer you, the cardiologist will do tests, the tests will be normal, you will feel better for a week, and then the next time you get a twinge, the cycle starts again. The investigations are actually part of the problem, not the solution.'

Offer treatment for the anxiety: CBT through IAPT with a focus on health anxiety, reduction of safety behaviours (stop pulse checking, stop Googling symptoms), and reassurance that if any genuinely new symptoms develop, you are available.

Time check: Minutes 1-4 on thorough symptom assessment. Minutes 4-6 on providing a positive musculoskeletal diagnosis and addressing the father's MI. Minutes 6-9 on naming the health anxiety and explaining the investigation cycle. Final 3 minutes on management plan including CBT referral, safety behaviour reduction, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you take a thorough chest pain history that identifies the musculoskeletal features and excludes cardiac characteristics. Asking about the A&E attendances, the pulse checking, and the online searching demonstrates recognition of health anxiety behaviours. Exploring the father's MI as the specific trigger shows clinical reasoning beyond symptom assessment.

Clinical Management and Medical Complexity: Examiners evaluate whether you provide a positive diagnosis (musculoskeletal chest pain, not just 'not cardiac'), decline further cardiac investigation with clear rationale, and offer a management pathway for health anxiety (IAPT referral for CBT). Explaining why further investigation is counterproductive — that it reinforces the anxiety cycle — demonstrates understanding of health anxiety management principles.

Relating to Others: Examiners look for empathetic engagement with his fear rather than dismissal. Connecting the anxiety to his father's MI, validating that the chest pain is real, and naming the anxiety pattern without making him feel silly are all essential. The patient should leave understanding both what is causing his chest pain and why the worry has become a problem, not feeling fobbed off or told it is 'all in his head.'

Example Opening

Strong opening: "Hello Aiden, I can see this chest pain has been really worrying you. I want to do a thorough assessment today so I can give you a clear answer about what is going on. Tell me about the pain from the start."

When naming the anxiety: "Aiden, I want to be honest about something I have noticed. The two A&E visits, the constant pulse checking, the hours spent researching online — these are signs that health anxiety has become a significant problem. And that is not a criticism — it makes complete sense given your dad's heart attack. But the anxiety itself needs treatment, because the investigations are not solving the problem."

Avoid: "Your ECGs were normal so there's nothing to worry about" — this provides temporary reassurance but does not address the underlying anxiety, does not explain what is causing the pain, and he has already had this conversation twice in A&E without lasting benefit.

How This Appears in the SCA

Chest pain with health anxiety tests your ability to conduct a thorough assessment, provide a confident positive diagnosis, and address the anxiety as a condition requiring treatment in its own right. Examiners value candidates who break the investigation-reassurance cycle rather than perpetuating it.

Key Statistic

Musculoskeletal chest pain accounts for approximately 20-50% of chest pain presentations in primary care. Reproducibility on palpation has a positive predictive value of over 95% for a musculoskeletal cause.

Relevant Guidelines

• NICE CG95: Chest pain of recent onset
• NICE CG113: Anxiety (generalised anxiety disorder and panic disorder)
• NICE CKS: Chest pain
• NICE guideline on health anxiety (within CG113).

Frequently Asked Questions

How do I confidently exclude cardiac chest pain in a young patient?

The key features that make cardiac chest pain unlikely are: pain that is sharp or stabbing rather than crushing or heavy, pain lasting seconds rather than minutes to hours, pain that changes with position or breathing, pain reproducible on chest wall palpation, no exertional relationship, and age under 35 with no significant cardiovascular risk factors. Two normal ECGs and normal troponin effectively exclude acute coronary syndrome. Providing a positive alternative diagnosis (musculoskeletal) is more reassuring than a list of what has been excluded.

Why does health anxiety cause chest pain?

Health anxiety creates a cycle: fear triggers the fight-or-flight response, which causes muscle tension throughout the body including the chest wall. This tension produces genuine musculoskeletal pain, which the patient interprets as evidence of cardiac disease, increasing the anxiety further. Additionally, hyperventilation during anxiety episodes can cause chest tightness and paraesthesia. The pain is real — it is not imagined — but it is maintained by the anxiety rather than by cardiac pathology. Explaining this mechanism helps patients understand why treating the anxiety treats the pain.

Should I investigate to provide reassurance in health anxiety?

Generally no, once reasonable exclusion has been achieved. Research shows that investigation in health anxiety provides only temporary reassurance (typically days to weeks) before the anxiety returns. Worse, each investigation reinforces the patient's belief that investigation is necessary, lowering the threshold for future presentations. The evidence-based approach is: conduct a thorough clinical assessment, provide a confident positive diagnosis, explain why further investigation is not indicated, and offer treatment for the anxiety itself through CBT.

What is the role of CBT in health anxiety?

CBT for health anxiety is the NICE-recommended first-line psychological treatment. It targets: catastrophic misinterpretation of bodily sensations, safety behaviours (pulse checking, symptom Googling, repeated medical consultations), and avoidance behaviours. Treatment typically involves 8-12 sessions and has strong evidence for sustained improvement. Refer through IAPT, specifying health anxiety as the presenting problem. Self-help resources based on CBT principles can be offered in the interim — the 'Overcoming Health Anxiety' self-help programme is widely available through IAPT services.

How do I handle the family history of MI as an anxiety trigger?

Acknowledge its significance: 'Your dad having a heart attack at 52 makes it completely natural to worry about your own heart.' Then contextualise the risk: at 24, with no other cardiovascular risk factors, the absolute risk is extremely low. Explain that family history increases lifetime risk, not immediate risk, and that appropriate screening (cardiovascular risk assessment from age 40, or earlier if multiple family risk factors) is the evidence-based approach. Reframe the father's MI as something to monitor long-term, not something that makes a heart attack imminent at 24.